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Your child is going to have a BMT. We know that families have lots of questions about BMT; we hope this pamphlet helps. If you have more questions, please ask your nurse or doctor.
Note: we will use both “he” and “she” throughout this pamphlet. Here are some words you might hear:
Allogeneic transplants are when your child gets stem cells (usually from bone marrow) from a donor (ie: sibling, parent, unrelated).
DMSO: this is added to stem cells that are collected from a donor who is far away or when the stem cells are not being given right away. It preserves the stem cells so that your child’s body can use them when they are infused into her.
Engraftment: when the new stem cells show signs they are growing. For example, when your child’s blood counts start to go up.
Preparative Regimen: the chemotherapy (and maybe radiation therapy) used to prepare your child’s body to receive the stem cells.
Stem Cells: Stem cells are the "seeds" out of which all blood cells develop. They are produced and grow in the bone marrow. Stem cells are found in:
• bone marrow (in the center of big bones)
• the bloodstream, especially after chemotherapy or when some medications are given to “push” the stem cells into the bloodstream
• umbilical cord blood of a newborn
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For information about 3B, the inpatient unit, and more about the Oncology Program refer to the Parent Handbook. Hardcopies are given to each family admitted to the program and can be found in the Family Resource Library.
What room will we be in? Can we choose our room?
There are 5 rooms for BMTs on 3B. If you have a room preference we will consider that. Note: Room assignments are based on the needs of each child; we will work hard to honor your room request. Please understand if we are not able to do so.
What do the rooms look like?
Some of the rooms have bathrooms attached; others do not. (We will bring a commode in and make sure we pay attention to privacy.)
Each room has: TV
DVD player telephone
What can we bring into the room?
Any clean personal items from your own home or those that are new (keep the plastic wrap on them if possible).
Plastic, glass, even electronics such as a tablet or computer: can be wiped with a disinfectant before they come into the room and weekly (more often if they get soiled).
Note:
- dishwasher-safe toys may be run through the dishwasher and immediately bagged as described below.
- bath toys that retain water should not be used when your child’s immune system is low
Clothes: should be washed in hot water, dried on high heat and immediately double bagged directly from the dryer (put into a bag, sealed or tied, put into another bag and sealed again). You may also use large plastic bins to store clothes and cleaned personal items. You may wash clothes/toys in cold water if you use detergent for cold water in amounts
recommended..Your own clothes do not need special cleaning. However, make sure you wear clean clothes every day. There is a washer/dryer on the 3rd floor that you can use. If you need to store your own clothes please double bag them or put them in plastic bins.
Note: Space is very tight on 2B/3B. The BMT rooms are very small; there is little room to store things in the room or outside of the room so please choose what you bring into the hospital with this in mind. You may store things at home or where you are staying and bring them in as needed.
oCloth/stuffed toys: clean as you would clothes. Make sure they are in the dryer long enough to get dry. Stuffing may take a very long time to dry. This should be done weekly and whenever they get soiled, as long as your child is in isolation.
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Books and other paper products, eg: cardboard: only from home or new ones (not library books or those from other children). Paper products cannot be wiped down.Note: If a cardboard box or board has a “finish”, ie it’s coated and won’t absorb the solution we use to wipe things, you can wipe it and bring it into the room.
Pictures or posters for the walls should be new, wrapped in plastic, or laminated. Food and drinks: must be stored outside the room. Meals will come specially wrapped
from the kitchen. If you bring food for your child, it must be prepared and stored in a special way. Talk to the dietitian about this. Parents may not eat in the room or anteroom. You may have a covered drink, eg: coffee/tea in the room; it should be removed after 2 hours.
Note: Re-usable water bottles for parents can be kept in the room as long as you want if they are capped. They should be washed with soap and water daily. Disposable bottles cannot be reused; they should be discarded after 24 hours. For patients, if the cap stays on and he doesn’t drink directly from the bottle, it can stay in for 24 hours; if he drinks from the bottle or it is uncapped, remove after 2 hours.
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Can he have visitors?
Only 2 visitors are allowed in the room at a time. Because his immune system will be knocked out, it will be harder to fight infections. This is why it is best to limit the numbers of people with whom he comes into contact. So choose about 3-5 people to visit inside the room. These people must be healthy. Screen visitors carefully; if anyone has had a cough, fever, vomiting, rash, diarrhea, has a runny nose or signs of a cold or the flu in the past 3 days, or has been exposed to a childhood or communicable disease (for example, measles, mumps, chicken pox or whooping cough in the past 3 weeks) or recently been given a live vaccine, they should not visit. Others can wave from the hallway outside the anteroom or room. No other children, except siblings who are healthy and have been screened, can visit. This includes other patients or patients’ siblings. Visitors, including you and your family, may not use your child’s bathroom.
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Where will the new stem cells come from?
The first step toward finding a donor that closely matches your child involves a simple blood sample. Blood will be taken from your child for tissue typing. Like finding a blood donor, tissue typing helps find a match for transplanting stem cells. Identical twins are exact matches for each other. Other members of the family may be close matches, and may be related donors. Sometimes, we have to go outside the family, to registries, to find a close match from an unrelated donor.
Since there are several sources of stem cells, your oncologist will tell you which source is the best for your child:
Related donor: usually a sibling or parent. Members of your immediate family may be asked to give a blood sample so it can be tested to see if your child has a match. Bone marrow or blood stem cells may be used.
Unrelated donor: may be bone marrow or cord blood. We go through a BMT registry to try to find a match for your child.
How are the stem cells collected?
Stem cells are collected in 3 ways:1. Bone marrow harvest:
Adults: If the donor is an adult, he will be harvested at Vancouver General Hospital. You will be given instructions by your oncologist or nurse practitioner.
Children: This is an outpatient procedure that takes place in the operating room. A nurse from the Surgical Day Care Unit (SDCU) will call you the day before the BMT to ask you for information about the health of the donor. She will tell you exactly what time to be there, usually at 6:30 AM on the day of the transplant. The donor will be taken to the operating room and given an anesthetic so he will not be awake during the
procedure. Once he is asleep, the oncologist will make a small cut over the flat bone that is below and on the side of his spine and next to his hips. She will use a needle to get to the center of the bone, which is where the bone marrow is. The bone marrow, a liquid in the center of the bone, is drawn into the needle with a syringe. Depending on the size of the patient and the number of stem cells in each withdrawal, this may have to be repeated several times to get enough stem cells. The donor’s body makes more bone marrow all the time; what is removed will be replaced in a few weeks. After the oncologist gets enough stem cells, a pressure bandage is placed on the sites where marrow has been removed and the donor is taken to the Post Anesthesia Recovery Unit (PACU) to recover from the anesthesia. The nurses will take his vital signs frequently
and monitor him closely. You will be able to visit him there. When he has recovered, he will go back to the SDCU where he will continue to be monitored. When he is able to keep fluids down, is passing urine, and is awake, you will be discharged home, usually around 3-5 PM. An adult should plan to be with the donor over night. Watch for the following:
Pain : the donor might experience some discomfort. The doctor will give him mild pain medicine. If this continues past 24 hours, call the doctor.
Bleeding: There may be some minor bleeding the first night. If this continues into the next morning, call the doctor.
Infection: If you see signs of infection (redness, swelling, pain, discharge) call the doctor.
The nurses in the SDCU will review the discharge instructions with you and tell you when to come back for your follow up appointment with the doctor or nurse practitioner.
Note: sometimes we admit the donor overnight. Your oncologist or nurse will let you know if this might happen.
2. Peripheral blood stem cell harvest or apheresis: stem cells are also in the bloodstream. The donor has a special IV and is hooked up to a machine that separates the blood. The stem cells are removed, taken to the lab, frozen, and stored until they are needed. If you or a family member are going to donate peripheral blood stem cells, your doctor or nurse will explain this further.
3. Umbilical Cord blood: Stem cells can also be collected from umbilical cord blood through cord blood banks.
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What will happen before the transplant?
Your child will have many tests and exams done before he is admitted for the transplant. These can be done as an outpatient, through the Oncology Clinic. Your doctor or nurse will explain them to you. Many are blood tests, some are x-rays or CT scans. Your child will also see some specialists, like the dentist and cardiologist. This helps us see how he is before the transplant and helps us compare how she is during and after the transplant.
Your child will be admitted to 2B/3B about a week before the transplant. We start his
“countdown” when he is admitted. This means, we count the days until the day of transplant (Day 0). Your child will be admitted around Day -7 or -10. This time might be different, depending on your child’s protocol. He will start the countdown by getting strong medications, called chemotherapy. We give chemotherapy for 2 reasons:
to get rid of any cancer cells or parts of the blood system that are causing your child’s problem
to clear the bone marrow space to make room for the new cells. The exact schedule, drugs and their side effects, will be explained by your doctor and nurse. You will be given a calendar and drug information sheets.
Note: Some children will get Total Body Irradiation (TBI) as part of their preparative regimen. This may be given to help kill some types of cancer cells. Your doctor or nurse practitioner will tell you if your child will get this.
What will happen on transplant day (Day 0)?
Your child will be moving into the BMT room either on Day 0 or Day -1. This is the room in which she will be receiving her stem cells, recovering, and waiting for engraftment. This room will be specially cleaned using a “BMT” protocol. Before entering the room, your child will take a bath (shower or in a tub), and put on the clothes you have specially cleaned (see guidelines above).
If your child is getting cells that have been preserved in DMSO (peripheral blood stem cells, bone marrow from a donor who is far away, and cord blood) we will give your child
medications before infusing the stem cells. This is to prevent a reaction to DMSO. Some side effects include nausea, vomiting, headache, pain in the abdomen, low blood pressure, slower heart rate and a red color in the urine (this is only for a short time). As the stem cells go into your child, you may notice a strong smell. Some people say it smells like garlic, others say it smells very strong and unpleasant. We will use some aromatherapy in the room when DMSO is used to help with the smell.
The stem cells, which have been put into a blood transfusion bag, are filtered in the lab where they remove fat, small pieces of bone and some fluid. They are brought to 3B. If they have been frozen, they are thawed in the lab and brought to your child’s room. they are given as a blood transfusion, through the central line, over a few hours.
The stem cells find the bone marrow spaces and within a few weeks grow and make new blood cells. Risks of the stem cell infusion are
fluid overload (we will give her medications to help her urinate if this happens) anaphylactic reaction (an allergic reaction which we treat immediately).
We will watch your child very closely, taking her vital signs (blood pressure, heart rate, respiratory rate, temperature, oxygen level in the blood) very often, even after the stem cells have gone in. This will be done using a cardiac monitor.
What do I need to do to go into the BMT room?
The first time you enter the room, the nurse will review:Handwashing:
Anyone entering the room (staff, family and visitors) must wash their hands for 1 minute (you should time yourself):
Remove all rings and watches and roll your sleeves up past your elbow. Nail polish and artificial nails should be removed.
Staff must wash again after patient contact and betweenpatients. Gowns:
Staff, family and visitors must wear a yellow protective gown before entering the patient room.
Gowns should be changed after direct contact with your child and if soiled or wet. Note: if you are sleeping in the room, you will need to wear a gown while sleeping. If you can’t, keep a clean gown in the room and put it on if you have to take care of or help your child.
What are the problems and side effects of an allogeneic BMT?
The preparative regimen, itself, will cause some side effects. Chemotherapy affects the cancer cells, but also the fastest growing cells in the body. These are found in the intestines, the hair follicles, and the bone marrow. This explains some of the side effects you might see.
Side effects from radiation therapy usually depend on what part of the body is being treated. Your radiation oncologist will review this with you, as well as effects from TBI, if you child is having this. Other side effects may be related to problems with her organs or with
engraftment.
oNausea/vomiting: mainly at the time chemo is given. We will give medications to control it.
oHair loss: she will lose all the hair on her head and maybe other parts of her body
(eyebrows and eyelashes). This is usually temporary and will start to re-grow (you may see this start in about a month) when the chemotherapy is out of her system.
oLack of blood cells: She will need transfusions of red blood cells and platelets. White blood cells (WBC), called neutrophils, are usually the first cells to come back; platelets are usually the last. We will watch her blood counts daily or more often if needed. When her blood counts come up we will know that she is engrafted.
oInfections: her WBCs will be very low. This means that it will be very hard for her to fight off infections. If she has a fever or other signs of infection, she will need medications to help her fight the infection. We will do blood cultures to make sure we are giving the right drug for the type of infection she has. Infections are the main problem that BMT patients have.
oGraft problems:
graft rejectionor graft failure: when the new donor cells do not stay engrafted or don’t engraft at all. You might hear us say “losing the graft”. Your doctor will discuss what we will do next if this happens.
Engraftment syndrome: As your child’s bone marrow starts to recover, she might get a fever or rash, gain weight and have problems handling fluids. This doesn’t happen very often. If your child gets engraftment syndrome, we will do blood tests, watch her very carefully, and support her through it.
oGraft vs Host Disease (GVHD): This only occurs in an allogeneic transplant, when there are differences between the donor and the patient even though we have matched them as closely as possible. The donor cells know they are in a different body and do what they are meant to do - they fight off “foreign” cells (in this case, your child’s body). GVHD may be mild or very severe, or your child may not get it at all.
We try to prevent GVHD by giving medications. In spite of this, sometimes transplant patients do get GVHD. There are medications that we use to treat GVHD, but sometimes children have it for a long time. There are 2 types of GVHD:
acute: 10-20% chance of having this within the first 100 days after the transplant. Liver, skin and intestinal tract may be affected. She may get a rash, diarrhea, abdominal pain, increase in liver function tests; these symptoms may be mild to severe. We treat acute GVHD with medications.
chronic: 10-15% chance of having this type after the first 100 days after transplant. Chronic GVHD may show up after getting the acute type or it can show up without having the acute type. This chronic form can be a life-long problem, with symptoms that may be hard to manage, although most of the time it burns itself out. Chronic GVHD can show up in:
eyes (dry) liver
heart (this is rare) kidneys
joints
lung problems infections
If your child gets chronic GVHD, your doctor or nurse practitioner will talk to you about the treatment plan.
Mucositis (mouth sores): may be sores in her mouth and through her intestines,
depending on what drug we use. It may get very uncomfortable and require intravenous (IV) pain medication. When her blood counts come up, the mucositis will be better and then go away.
Nutrition: good nutrition is very important in helping your child get better. Stem cells grow better when your child’s body is well nourished. It is very hard for children to maintain the best nutrition when they are getting a BMT. They may try very hard to eat or may be turned off of food. If she can’t eat, no amount of encouragement will help. Check the guidelines for diet and nutrition and food safety tips at the end of this pamphlet.
We usually need to feed her through a small feeding tube (called an NG tube - goes in through her nose and down into her stomach). This is the best way to give her nutrition since it keeps the gut working. We will place the NG tube right before or right after she gets her stem cells. We have to do it before she has mouth sores. Your nurse will explain this to you and your child. Your dietitian will go over your child’s feeding plan in the hospital and when you are ready to go home.
Some children need TPN (total parenteral nutrition), which is feeding her nutrients through her central line. When she is admitted, the dietitian will meet with you to talk about the nutrition plan.
oProblems with the liver: The liver cleans the blood, stores energy, breaks down drugs and helps digestion. We will be doing blood tests and exams to watch for any signs of problems, like weight gain, holding on to water (puffiness in face, hands, feet, or body). For example, veno-occlusive disease (VOD; also called “SOS”: sinusoidal obstruction syndrome) is a problem that BMT patients sometimes get. If you child gets this, your doctor and nurse will talk to you about treatment. We will likely give her some medication to try to prevent liver problems.
oEffects on other organs: chemotherapy does not only effect the bone marrow, but other organs as well. We use those tests of his heart, lungs, kidneys he had before the transplant to help us see how his organs are doing. Some patients may have organ damage as a result of the chemotherapy.
Note: Sometimes transplant patients may need the special services of the Intensive Care Unit (ICU). If your child is very sick, needs breathing support, or if he needs special monitoring or medication to support his blood pressure or other body functions, and we cannot care for him on 3B, it may be safer for him to be cared for in the ICU. The most likely reason for going to the ICU is an infection. While he is there, the ICU team will be caring for him and making the day to day decisions. The transplant team will help guide BMT decisions and care. We work closely together to give your child the best care. As soon as he does not need these special services, he will come back to 3B.
There is a small risk that she could die from the side effects of the BMT. The major cause of death is overwhelming infection. We will talk with you more about this if needed.
What will our days look like when we are in the BMT room?
Your daily schedule will depend on your child. She may be having side effects and need a lot of care (ie, blood and platelet transfusions, IV fluids, pain medications, antibiotics, etc). She may not feel like doing much. Each day, your nurse will review the plan for the day. This has to be flexible - it will depend on your child’s needs. You can expect:
o Wake up at 8 AM; if you are sleeping in the room, your cot should be folded up by 8 AM. A nurse will be doing:
vital signs (temperature, blood pressure, heart rate, respiratory rate) at least every 4 hours around the clock (may be more often if needed)
physical exams (at least at the beginning of every shift; more often if needed) A doctor will be checking her at least once a day and as needed
Bloodwork will be done every day and as needed, usually between 4 and 6 AM. This is so the doctors will have the most up to date information when they plan each day’s care.
Other tests (ie, x-rays, scans, etc) will be done as needed, depending on your child’s condition
Daily weights (maybe more frequently if we are concerned about his nutrition and fluid balance) are usually done by 10 AM.
Daily baths. If you are in a room without a bathroom, he may go to the tub room. If he is too sick to take a bath, he will have a sponge bath. He will use a mild soap. After rinsing
thoroughly (use hand held shower head if possible), generously apply a moisturizing cream. We provide the soap and moisturizers. Linens are changed daily and as needed. The linens on your parent bed should also be changed daily.
Note: Because your child’s skin is sensitive after a BMT, you may not use your own skin care products. Even products labeled for sensitive skin often contain chemicals that can irritate. Many are not fragrance-free.
o Toileting: After a bowel movement or if using diapers, clean with damp wipes. After both a bowel movement and passing urine, dry gently and well. If her skin is irritated, we will use a cream to protect her skin and treat/prevent skin breakdown. After toileting patients clean their hands with soap and water or hand sanitizer.
Mouthcare: this is very important since she will not be able to fight off infections. She will need to do mouthcare at least 4 times each day with a toothbrush or toothette and rinse with a bicarbonate solution. She may need to suction thick saliva that is hard to spit out on her own.
o Exercise. It is important that your child get out of bed and move as much as she can. Even sitting on the side of the bed or in a chair is better than lying in bed. If your child needs it, your nurse will be there to help. Of course, all this depends on how your child feels and his medical needs. If moving and exercise are tough for your child, the nurse can contact the physical therapist for help. Talk to your nurse about this.
The child life specialist will work with your child daily, if he feels up to it. Check with her to see what time is best.
The music therapist is available at times throughout the week. She will check in with you.
Others who might spend time with your child include the dietitian, spiritual care, social worker, psychologist, teacher, and occupational therapist.
Tip:
When others are with your child, use the time for yourself: rest, exercise, meals. Plan to have a friend meet you for a coffee break or a walk.
What can we do to help prevent infections?
Most infections in BMT patients are from bugs that are already in their own bodies. We can’t prevent those infections. But we can try to prevent infections that come from outside his body. So the most important things you can do:
o Good handwashing: before you come into the room, if your hands get dirty in the room, after helping your child with toileting
o Daily baths
o Good mouthcare, at least 4 times each day. Your nurse will show you how.
o Do not leave food in the room for more than 2 hour
o Do not leave open drinks in the room for more than 2 hours. (Capped bottles can stay in for 24 hours)
Here are some more things you and your child should do:
o Make sure anything that comes into the room is cleaned (see above)
o Do not walk with bare feet.
o Consider the floor “dirty”: anything that drops on the floor has to be kicked out of the room. It cannot come back in until it has been properly cleaned.
o Keep the door to your room closed at all times
o Choose visitors carefully (see above)
o No live plants or flowers
How will we know that the new cells are growing (engraftment)?
Usually within 14-21 days we see signs of engraftment: blood counts begin to come up. This means that she will be able to fight infections better; if there is any mucositis, it should get better; and the need for blood product transfusions will decrease. The neutrophils are usually the first to grow, and the platelets are usually the last. As the new cells grow, you may see the blood counts go up and down. This is normal. We will be watching this very closely.
How long will we have to stay in the BMT room?
When her absolute neutrophil count (ANC) is 0.5 (you may hear “500”) for 2 days together, and if she does not have any infections, she can go on “stepdown isolation”. This means she
can come out of the BMT room, walk around the ward (wearing a mask) or go to the playroom (no other patients or visitors will be allowed to come in while she is there); this needs to be checked with the child life specialist. Once on stepdown, your child may be moved to another single room on the unit. Sometimes, passes out of the hospital are allowed. Decisions about isolation depend on your child’s health and safety. Check with your nurse about what is safe for your child.
When can my child go home?
After stepdown isolation, you can go home when:
ANC is 0.5 (you may hear “500”) or higher for at least 2 days together Able to keep up her nutrition by NG tube feedings or by mouth
No fever or signs of infection Limited need for transfusions
Able to take medications by mouth or NG tube
When we see signs of engraftment, we will start talking to you about going home. The nurses will start discharge teaching and you will receive a pamphlet called “Going Home After an Allogeneic Transplant”.
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Can we get flu shots?
Yes! We encourage you to get flu shots. Check with your GP, since we cannot give them to you here at the hospital. If you live outside the Lower Mainland, you will have to get a flu shot from a community clinic. Check with your oncologist or nurse about flu shots for the child who will be getting a BMT.
Where can I get more information?
Please ask your doctor or nurse for more information or if you have questions. You can also get information from:
The Family Resource Library. It is located on the 2nd floor of the Ambulatory Care Building and online: http://www.bcchildrens.ca/KidsTeensFam/FamilyResourceLibrary/default.htm Internet resources that you might find helpful:
UCSF Childrens Hospital:
http://www.ucsfhealth.org/childrens/medical_services/cancer/bmt/moreinfo/patient_educati on.html
National Cancer Institute:
http://www.cancer.gov/cancertopics/factsheet/Therapy/bone-marrow-transplant Blood and Marrow Information Network: http://www.bmtinfonet.org/
“Me and My Marrow” (an excellent book for children):
